addiction: the devil you can measure and the devil you can’t

If you take too much heroin, your breathing slows until you die. Unfortunately, the drug sets an addictive trap that is sinister and subtle. It provides a euphoria—a feeling of contentment, simplification, and release—which users swear has no equal. Users quickly develop a tolerance, requiring higher and higher amounts to get the same effect. The dosage required to attain the feeling the user originally experienced rises until it is higher than the dosage that will kill him. An addict can get more or less “straight,” but approaching the euphoria he longs for requires walking up to the gates of death. If a heroin addict sees on the news that a user or two has died from an overly strong batch of heroin in some housing project somewhere, his first thought is, “Where is that? That’s the stuff I want.”

I appreciate Caldwell’s no-holds-barred approach to opioid addiction. He perceptively wades through the statistics that help us to understand the scope of the problem, observing that what we face now is, from an epidemiological standpoint, 5 to 10 times more deadly than the previous drug epidemics that launched America’s War on Drugs.

When it comes to treatment, though, Caldwell gets wobbly. He feels that political correctness has infiltrated the field of addiction treatment, applying Foucaultian devilry to terms like “drug abuse” and “clean urine” to the point that we will mask the moral severity of addiction with euphemisms. He also resists the overmedicalization of the addiction before affirming the usefulness of 12-Step and peer recovery models:

Medical treatment plays an obvious role in addressing the heroin epidemic, especially in the efforts to save those who have overdosed or helping addicts manage their addictions. But as an overall approach, it partakes of some of the same fallacies as its supposed opposite, “heartless” incarceration. Both leave out the addict and his drama. Medicalizing the heroin crisis may not stigmatize him, but it belittles him. Moral condemnation is an incomplete response to the addict. But it has its place, because it does the addict the compliment of assuming he has a conscience, a set of thought processes. Those thought processes are what led him into his artificial hell. They are his best shot at finding a way out.

I mostly agree with this critique, although the last two sentences are quite amusing for anyone who is familiar with addiction treatment and its common truism, “Your own best thinking got you here.” Yet in many ways he’s still right: but the psychological counseling he is suspicious of (known in the medical literature as cognitive-behavioral therapy or CBT) is all about helping people use their thought processes to overcome addiction. He seems quite fond of 12-Step programs and peer recovery while distrusting counseling and medication, yet the scientific evidence on the whole suggests that they’re all about equally effective. Opioid treatment programs in particular tend to mix-and-match; when I was prescribing Suboxone (buprenorphine), my patients would meet with an individual counselor, see me for their prescription, and then go to a peer recovery meeting.

As far as language goes, I think the desire to remove stigma sometimes goes overboard. Some of the changes in language, though, are attempts to be more precise: “substance use disorder”, for example, would ring more true than “addiction” to describe someone who only gets high on weekends but isn’t physically dependent on his or her drug of choice. Furthermore, these are mostly concerns for the higher echelons of doctors and journalists: in my experience most counselors and peer recovery coaches are salt-of-the-earth types who are generally resistant to politically correct mumbo-jumbo unless they feel like it’s helpful.

I took up the question of addiction as a disease here, and I think it is worth saying that a reductive understanding of disease severely hinders us in this discussion. Some of Caldwell’s politically correct interlocutors are fond of saying that “addiction is a disease, just like diabetes”. I think that’s true: most cases of diabetes require medication to reckon with faulty biological systems, but all cases of diabetes require changes in diet that require patients to apply themselves with moral and spiritual discipline. Far too many doctors and patients think that managing chronic illness is as simple as passively receiving information and taking medications, rather than working together to develop the habits necessary for a healthy life. We have to start by accepting that choices– and, yes, character– have a lot to do with managing any chronic disease.

Caldwell grants the usefulness of medications, but never explicates the value of methadone or Suboxone. I’m working on a longer essay considering the theological and moral issues we have to wrestle with when it comes to opioid replacement therapies like these, but access to these medications is a crucial policy question right now that we must address. I think that addicts should have the option of these medications available to them because they do help people to stop using drugs in harmful ways, but making these therapies available is not cheap and is not necessarily popular. (A more challenging question is that of medical marijuana, which seems to reduce opioid overdoses in states where it is available.)

Lastly, I want to draw out something Caldwell hints at, where at the end he speaks of “the nether world” of addiction. I think this is absolutely something true, although I am sure the rationally driven medical establishment would dismiss it as poppycock. Eve Tushnet asks, “What if addiction isn’t a thing?” and I want to ask: “What if addiction is a spiritual power?” That is, what if addiction is the hole between the physical world of neurochemistry and the spiritual world where demonic powers slip in to control us? Christians are willing to acknowledge that spiritual evil manifests itself in a variety of physical authorities (for more on this, see Walter Wink’s Naming the Powers), what if we were willing to acknowledge that this is an evil force pushing a human will in the wrong direction?

This schema, I think, would help us to tie our instincts to recognize the moral nature of addiction and the need for developing character and willpower to resist addiction while also acknowledging the usefulness of the more scientific and rational approaches. One is narrowing the size of the hole and the other is putting a mesh over it. Unless you’re getting a medication to restart your heart after it has stopped, most pharmaceuticals are about giving people an edge over their physical hindrances such that their own efforts to eat healthier or be less depressed can actually work. Our physical and spiritual realities and the character or will that directs them can never truly be separated; using Suboxone or methadone in tandem with counseling, peer support, and prayer takes this seriously.

Caldwell, like many doctors and addictions counselors, seems very open to this sort of both/and approach, even if the medical establishment is boxed in by rationalistic presuppositions. More Christian primary care doctors should start prescribing buprenorphine and more secular addictions counselors need to recognize that they are not battling flesh and blood alone. To respond to an epidemic of this magnitude, we are going to need every weapon we’ve got.

Posted by Matthew Loftus

Matthew Loftus teaches and practices Family Medicine in Baltimore and East Africa. His work has been featured in Christianity Today, Comment, & First Things and he is a regular contributor for Christ and Pop Culture. You can learn more about his work and writing at www.MatthewAndMaggie.org

3 Comments

I think you’ve heard this from me before, and if you know my history you can take it with a grain of NaCl, but I had to say, Go away in the name of Jesus to break the power of sugar in my life… and I will again…. Overeating is also an addiction and will kill me if it rules my life. And yes, the 12 steps teach submission to God’s will, which is absolutely vital. Our brains were made to worship God and have fellowship with him which is euphoric if you have experienced that. I remember waking up from surgery and feeling that happiness from a fentanyl relative, but that temporary happiness is not as wonderful as the presence of the Holy Spirit after say, witnessing to a friend and they accept Jesus as their Saviour right then. That euphoria lasted a full day. Well, just my addict two cents… thanks for listening…